Surgeons Take Critical Look at Their Process

From left, Heather Hardy, Alicia Titzmann and Misty Blanchette Porter are part of a surgery demonstration about cutting waste from the tools and steps used in the operating room at DHMC. (Valley News - Jennifer Hauck) Purchase photo reprints »

Two similar but differently priced items are part of the Value Institute display at Dartmouth-Hitchcock. (Valley News - Jennifer Hauck) Purchase photo reprints »

Lebanon — Anyone who has done a bit of hiking understands the importance of packing light.

Take only what you need. If you add a new piece of equipment to your pack, take out whatever it is meant to replace. There’s no reason to burn precious energy carrying unnecessary stuff.

The same rule should apply to surgeons. But, for the longest time, it just hasn’t worked that way at Dartmouth-Hitchcock, said Kris Strohbehn, a surgeon in obstetrics and gynecology. “If I was going to hike Mount Moosilauke every day of the year and each day having to add something, at the end of the year, I’ve got a whole lot of extra stuff,” he said. “We don’t think about that every day in the (operating room). But at the end of the week, we’re wasting a whole lot of resources.”

Lately, however, Strohbehn and his colleagues in OB/GYN have been thinking more about the tools they use, what is necessary and what can be done away with. And in the process, they estimate they are saving tens of thousands of dollars for the hospital.

For the past year and a half, departments throughout Dartmouth-Hitchcock have been taking a closer look at how they work to figure out better, more efficient ways of delivering care. The initiative, known as the “Value Institute,” borrows lessons from the world of business and industry and applies them to health care to educate the doctors, nurses and other staff throughout the Dartmouth-Hitchcock system about how to think critically about how they can improve the ways in which they perform their jobs.

The total expected savings so far from this effort are around $1.2 million. And these savings will grow as the initiative gets rolled out to more departments throughout the system.

At a time when pressure is growing on health care providers to control costs while improving outcomes for patients, the Value Institute’s approach is seen as a crucial component to helping Dartmouth-Hitchcock adjust to a new era in which providers will be held accountable for more of the decisions they make.

“It’s a combination of having talented people with the right tools,” said George Blike, chief quality and value officer at Dartmouth-Hitchcock. “The challenging thing in health care is, for every patient every time, doing what matters.”

It is not intended to be a one-time fix, Blike said. Rather, the goals for this initiative are to shift the culture at Dartmouth-Hitchcock over the next decade to one that not only seeks to improve the quality of medical care, but also improve the processes for delivering that care.

The Value Institute, part of the Quality Safety and Value Division at Dartmouth-Hitchcock, is an educational model, an approach to providing education, coaching and support to Dartmouth-Hitchcock employees that encourages them to improve what they do constantly.

Manufacturers such as Toyota have become famous for regularly rethinking the way they build cars with the aim of constant improvement. That’s what health care is beginning to do, as well, said Daniel Herrick, a senior value performance specialist at the Value Institute.

Before Herrick jumped into health care in 1989, he was part of the manufacturing world as an employee at Revlon, the beauty products company. It was a sector that began looking critically at improving systems much earlier than health care. Health care providers are used to incorporating new technology and advances in medicine to improve care, but traditionally, they haven’t been looking at processes, or as Herrick says, “flows.”

“We’re changing the culture here so that everyone is looking to the flows. It’s really trying to improve overall,” he said. “In health care, we’re migrating from the clinical side and looking more at flows, the processes.”

The training offered through the Value Institute, based on a methodology called “Lean Six Sigma,” essentially creates an army of specialists in each department who lead their colleagues through projects aimed at improving a particular way of doing things.

Heather Hardy is one of those specialists. Hardy, a project coordinator in perioperative services, led a team of OB/GYN and general surgeons that included Strohbehn in looking at the instrument kits they use for various procedures. The kits had become too large over time. It is easy to add instruments when new and better tools become available, Strohbehn said. But when they would put something in, they wouldn’t take out the tool that it was meant to replace. So the surgery kits just got bigger and bigger. That means more unnecessary expense to buy, clean, sterilize and assemble them.

“It’s easy to put a new instrument in surgical kits,” Strohbehn said. “It’s hard to get them back out.”

The vaginal hysterectomy kit, for example, had 110 instruments in it. Hardy laid out each instrument before a small group of surgeons and surgical technicians, and then had each person go through and tag the instruments he or she used most often. Each tool also was labeled with a price tag. Knowing the cost sparked discussions among each team about the real value of an item. Was this $49 suturing kit really necessary when a less expensive kit would serve just as well?

In the end, the team eliminated nearly half of the tools in the kit, cutting it from 110 instruments down to 58.

“It became readily apparent that a lot of stuff was being opened that was never used,” said Misty Blanchette Porter, medical director for assisted reproductive technologies and infertility at Dartmouth-Hitchcock Medical Center.

Seeing the prices on each item was a wake-up call for many of the doctors, Porter said. But just because an item was expensive didn’t mean that they automatically threw it out. In cases where one surgeon truly felt a particular tool was needed but that others didn’t use, arrangements were made to have that tool wrapped separately from the rest of the hysterectomy kit and made available when that surgeon was in the operating room.

Porter said the process of going through each tool also provided a learning opportunity for the other surgeons. They learned about the techniques employed by their peers and, when someone used a tool they didn’t, they could ask them, “why do you use that?” she said.

Not everyone at Dartmouth-Hitchcock has been so eager to get involved with the program, and some have been resistant to change, Hardy said.

“A lot of people come in and do something every day and they don’t want to look at it another way,” she said. “I have had certain experiences where they say, ‘We don’t want to change anything. Our kits are as efficient as they need to be.’ ”

Once most people begin going through the process, however, their minds change, she said.

Sue McGrath, an adjunct professor at The Dartmouth Institute and former engineering professor who developed the Value Institute curriculum, said the buy-in from employees comes when they realize that they are driving the changes. No one is forcing them to get rid of a particular clamp, for example, or alter a procedure.

“We’re not pointing fingers at people,” she said. “This is trying to diagnose issues in the system.”